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Park EH, O'Donnell T, Fritz J. Dual-Energy Computed Tomography Applications in Rheumatology. Rheum Dis Clin North Am 2025; 51:361-382. [PMID: 40246445 DOI: 10.1016/j.rdc.2025.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
Abstract
Dual-energy computed tomography (DECT) has emerged as a transformative tool in the past decade. Initially employed in gout within the field of rheumatology to distinguish and quantify monosodium urate crystals through its dual-material discrimination capability, DECT has since broadened its clinical applications. It now encompasses various rheumatic diseases, employing advanced techniques such as bone marrow edema assessment, iodine mapping, and collagen-specific imaging. This review article aims to examine the unique characteristics of DECT, discuss its strengths and limitations, illustrate its applications for accurately evaluating various rheumatic diseases in clinical practice, and propose future directions for DECT in rheumatology.
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Affiliation(s)
- Eun Hae Park
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, USA; Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Geonjiro 20, Deokjin-gu, Jeonju, Jeollabukdo 54907, Republic of Korea
| | - Thomas O'Donnell
- CT Research Collaborations Siemens Healthineers, Malvern PA, USA
| | - Jan Fritz
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, USA.
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2
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Strickland CD. Current Techniques in the Imaging of Gout. Semin Musculoskelet Radiol 2025; 29:267-274. [PMID: 40164082 DOI: 10.1055/s-0045-1802351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2025]
Abstract
Gout is a common inflammatory arthritis with well-described imaging characteristics. Radiography depicts erosive change and in advanced cases, tophus deposition near joints and in association with tendons or bursae. Computed tomography demonstrates the same features but may also use dual-energy or photon-counting techniques that allow for tissue composition analysis and the specific identification of monosodium urate deposition. Magnetic resonance imaging (MRI) is useful in identifying tophi and the damage associated with gout, such as bone erosion and cartilage loss in advanced cases. MRI also helps differentiate gout from other types of inflammatory arthritis, infection, or tumor that may have a similar clinical presentation. Ultrasound is widely used in the diagnosis of gout and also useful in procedural guidance of joint aspiration or soft tissue biopsy.
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Affiliation(s)
- Colin D Strickland
- Department of Radiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
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Park EH, O'Donnell T, Fritz J. Dual-Energy Computed Tomography Applications in Rheumatology. Radiol Clin North Am 2024; 62:849-863. [PMID: 39059976 DOI: 10.1016/j.rcl.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Dual-energy computed tomography (DECT) has emerged as a transformative tool in the past decade. Initially employed in gout within the field of rheumatology to distinguish and quantify monosodium urate crystals through its dual-material discrimination capability, DECT has since broadened its clinical applications. It now encompasses various rheumatic diseases, employing advanced techniques such as bone marrow edema assessment, iodine mapping, and collagen-specific imaging. This review article aims to examine the unique characteristics of DECT, discuss its strengths and limitations, illustrate its applications for accurately evaluating various rheumatic diseases in clinical practice, and propose future directions for DECT in rheumatology.
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Affiliation(s)
- Eun Hae Park
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, USA; Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Geonjiro 20, Deokjin-gu, Jeonju, Jeollabukdo 54907, Republic of Korea
| | - Thomas O'Donnell
- CT Research Collaborations Siemens Healthineers, Malvern PA, USA
| | - Jan Fritz
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, USA.
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Lennartz S, Zopfs D, Große Hokamp N. Dual-energy CT revisited: a focused review of clinical use cases. ROFO-FORTSCHR RONTG 2024; 196:794-806. [PMID: 38176436 DOI: 10.1055/a-2203-2945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Simon Lennartz
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David Zopfs
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nils Große Hokamp
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Dalbeth N, Botson J, Saag K, Kumar A, Padnick-Silver L, LaMoreaux B, Becce F. Monosodium urate crystal depletion and bone erosion remodeling during pegloticase treatment in patients with uncontrolled gout: Exploratory dual-energy computed tomography findings from MIRROR RCT. Joint Bone Spine 2024; 91:105715. [PMID: 38447697 DOI: 10.1016/j.jbspin.2024.105715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/19/2024] [Accepted: 02/21/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Monosodium-urate (MSU) crystal deposits can be visualized and quantified with dual-energy CT (DECT). Pegloticase lowers serum urate (SU) in uncontrolled gout patients, with methotrexate (MTX) co-therapy recommended to increase SU-lowering response rate and decrease infusion reaction risk. The literature on serial DECT-imaging during pegloticase+MTX co-therapy is sparse, with only 2 prior cases of rapid MSU deposition depletion with subsequent bone-erosion remodeling reported from a small open-label trial. Here, we report DECT findings during pegloticase treatment in a larger number of patients from a randomized controlled trial to confirm bone-erosion remodeling that follows MSU depletion with pegloticase. The influence of length-of-therapy is also explored. METHODS Patients received pegloticase (8mg every 2weeks)+MTX (15mg/week orally) or pegloticase+placebo (PBO) during the MIRROR RCT trial. A subset underwent DECT-imaging on Day1 (first pegloticase infusion) and at Weeks 14, 24, and 52. Patients with paired baseline-Week 52 images were included. Imaged regions with baseline MSU-crystal volume (VMSU)<0.5cm3 were excluded to minimize artifact contributions. VMSU and bone-erosion remodeling were assessed. RESULTS Eight patients (6 MTX, 2 PBO) were included. Included patients had received 52weeks (5 MTX), 42weeks (1 PBO), and 6weeks (1 MTX, 1 PBO) of pegloticase therapy. Patients who prematurely discontinued pegloticase maintained SU<6mg/dL on allopurinol (n=2)/febuxostat (n=1). At Week 52, VMSU had markedly decreased in both the pegloticase+MTX and pegloticase+PBO treatment groups, with faster depletion during pegloticase therapy. Bone-erosion remodeling was observed in 29/42 (69%) evaluated erosions: 29 (69%) size decrease, 4 (9.5%) recortication, 3 (7.1%) new bone formation. CONCLUSION Rapid VMSU depletion during pegloticase therapy was observed with concomitant bone remodeling within 1year. Following pegloticase discontinuation, VMSU reduction slowed or stopped even when SU was maintained<6mg/dL with oral ULT. CLINICAL TRIAL REGISTRATION NCT03994731.
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Affiliation(s)
- Nicola Dalbeth
- Department of Medicine, University of Auckland, M&HS Building 507, 28 Park Ave. Grafton, 1023 Auckland, New Zealand
| | - John Botson
- Orthopedic Physicians Alaska, 3801 Lake Otis Parkway, 99508 Anchorage, AK, United States
| | - Kenneth Saag
- University of Alabama at Birmingham, 2000 6th Ave. South, Floor 3, 35233 Birmingham, AL, United States
| | - Ada Kumar
- Horizon Therapeutics plc (now Amgen, Inc.), 1 Horizon Way, 60015 Deerfield, IL, United States
| | - Lissa Padnick-Silver
- Horizon Therapeutics plc (now Amgen, Inc.), 1 Horizon Way, 60015 Deerfield, IL, United States.
| | - Brian LaMoreaux
- Horizon Therapeutics plc (now Amgen, Inc.), 1 Horizon Way, 60015 Deerfield, IL, United States
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, University of Lausanne, rue du Bugnon 46, 1011 Lausanne, Switzerland
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Akella DS, Ghezavati A, Siddiqui HA, Erbele ID. Middle Ear Tophi: A Case Series of Two Unusual Lesions and a Report of Facial Weakness and Review of the Literature. Otol Neurotol 2024; 45:e333-e336. [PMID: 38478411 DOI: 10.1097/mao.0000000000004159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
OBJECTIVE Tophaceous lesions of the middle ear from calcium pyrophosphate deposition disease (CPPD, or pseudogout) and gout are infrequently reported. Recognizing its characteristic findings will allow clinicians to accurately narrow the differential diagnosis of bony-appearing middle ear lesions and improve management. PATIENTS Two consecutive cases of tophaceous middle ear lesions presenting to a tertiary care center between January 2021 and December 2021. Neither with previous rheumatologic history. INTERVENTIONS Surgical excision of tophaceous middle ear lesions. MAIN OUTCOME MEASURE Improvements in facial weakness and conductive hearing loss. RESULTS The first case was a 66-year-old gentleman with progressive conductive loss, ipsilateral progressive facial weakness over years, and an opaque, irregular-appearing tympanic membrane anterior to the malleus found to have CPPD on surgical pathology, with immediate postoperative improvement of facial function. The second was a 75-year-old gentleman with progressive conductive loss and similar appearing tympanic membrane as case 1, previously diagnosed with tympanosclerosis, found to have gout on surgical pathology. In both cases, the CT showed a heterogenous, bony-appearing lesion in the middle ear, and both tophaceous lesions were a of gritty, chalky consistency intraoperatively. CONCLUSION Tophaceous lesions of the middle ear are rare but have similar findings. Notably, the tympanic membrane can appear opaque and irregular, and the CT demonstrates a radiopaque, heterogeneous appearance. Facial weakness is an unusual finding. Specimens of suspected tophi must be sent to pathology without formalin for accurate diagnosis.
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Affiliation(s)
- Deepthi S Akella
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio
| | - Alireza Ghezavati
- Department of Anatomic and Clinical Pathology, University of Texas Health Science Center, San Antonio
| | | | - Isaac D Erbele
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, Texas
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Hu F, Xue L, Zhao D, Chen C, Liu G, Yang Q. Spinal gout with intervertebral foramen infiltration: A rare case perfectly mimicking degenerative lumbar disc disease. Exp Ther Med 2024; 27:66. [PMID: 38234610 PMCID: PMC10792407 DOI: 10.3892/etm.2023.12354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/28/2023] [Indexed: 01/19/2024] Open
Abstract
Spinal gout is a relatively rare disease characterized by significant clinical symptoms. In the current study, the first case of spinal gout with tophus in the intervertebral foramen, which perfectly mimicked degenerative lumbar disc disorders, was presented. The patient was a 57-year-old man with a medical history of gout who had suffered from progressive neurological deterioration for the last 12 months. Imaging examination revealed bilateral stenosis in the L5/S1 intervertebral foramen, mimicking degenerative lumbar disc disease. Nerve root radiculography and blocking were performed and the neurological symptoms were completely relieved. Open surgery was further performed and unexpectedly, the intra-operative findings were amorphous chalky white lesions. Histopathology confirmed the diagnosis of spinal gout. After surgery, the patient was prescribed a medication and achieved complete remission of clinical symptoms. No deterioration was found at the 1-year follow-up. To the best of our knowledge, this is the first report of spinal gout tophus in intervertebral foramen in the literature. It was concluded that, although intraspinal tophaceous gout is relatively rare, orthopedic surgeons should take it into consideration as a differential diagnosis, particularly if the patient has a medical history of gout. Early diagnosis and timely medical management may possibly be able to avoid neurological compromise and the need for surgery.
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Affiliation(s)
- Fangke Hu
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin 300000, P.R. China
| | - Lu Xue
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin 300000, P.R. China
| | - Dong Zhao
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin 300000, P.R. China
| | - Chao Chen
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin 300000, P.R. China
| | - Gang Liu
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin 300000, P.R. China
| | - Qiang Yang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin 300000, P.R. China
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Meer E, Patel M, Chan D, Sheikh AM, Nicolaou S. Dual-Energy Computed Tomography and Beyond: Musculoskeletal System. Radiol Clin North Am 2023; 61:1097-1110. [PMID: 37758359 DOI: 10.1016/j.rcl.2023.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Traditional monoenergetic computed tomography (CT) scans in musculoskeletal imaging provide excellent detail of bones but are limited in the evaluation of soft tissues. Dual-energy CT (DECT) overcomes many of the traditional limitations of CT and offers anatomical details previously seen only on MR imaging. In addition, DECT has benefits in the evaluation and characterization of arthropathies, bone marrow edema, and collagen applications in the evaluation of tendons, ligaments, and vertebral discs. There is current ongoing research in the application of DECT in arthrography and bone mineral density calculation.
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Affiliation(s)
- Emtenen Meer
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada; King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.
| | - Mitulkumar Patel
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
| | - Darren Chan
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
| | - Adnan M Sheikh
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
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Holbrook HS, Calandruccio JH. Management of Gout in the Hand and Wrist. Orthop Clin North Am 2023; 54:299-308. [PMID: 37271558 DOI: 10.1016/j.ocl.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Gout, or monosodium urate deposition disease, is the most common form of inflammatory arthritis that affects almost 4% of adults in the United States.Medical management involves lifestyle modifications and urate-lowering therapy to reduce the frequency of gout flares, decrease the tophi size, and improve upper extremity function. Goals for surgical management of gout include functional optimization, symptomatic treatment, and cosmetic restoration.This article focuses on the medical and surgical treatment of the common manifestations of gout in the upper extremity including tophi, tenosynovitis, joint contractures, neural compression, and arthropathy.
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Affiliation(s)
- Hayden S Holbrook
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - James H Calandruccio
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA
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Choi H, Ryu J, Lee S, Kim YJ, Bang S. [Detection of Monosodium Urate Crystal of Hand and Wrist in Suspected Gouty Arthritis Patients on Dual-Energy CT and Relationship with Serum Urate Level]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:212-225. [PMID: 36818719 PMCID: PMC9935968 DOI: 10.3348/jksr.2021.0003n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/24/2022] [Accepted: 05/17/2022] [Indexed: 02/10/2023]
Abstract
Purpose We retrospectively investigated the characteristics of patients with monosodium urate (MSU) deposits of the hand and wrist on dual-energy CT (DECT) compared to those without. We also attempted to determine the pattern of MSU distribution in DECT. Materials and Methods In total, 93 patients were included who had undergone DECT for evaluation of the hand or wrist pain under the clinical impression of gouty arthritis. The total volume of MSU deposits on DECT was calculated and the pattern of MSU distribution on DECT was analyzed. Also, the level of the serum urate at the time of DECT and the highest level of the serum urate of the patients were obtained from their records and the relationship between MSU and serum urate level was evaluated. Results The range of the volume of MSU deposits on DECT was 0.01-16.11 cm3 (average: 1.07 cm3). The average level of serum urate was significantly higher in the MSU positive group than that in the MSU negative group. MSU deposits were most frequently observed in the wrists followed by fingers and digitorum tendons. Conclusion On DECT, MSU deposits were most frequently detected in the wrist and related with high serum urate level.
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Affiliation(s)
- Hana Choi
- Department of Radiology, Hanyang University School of Medicine, Guri Hospital, Guri, Korea
| | - Jeongah Ryu
- Department of Radiology, Hanyang University School of Medicine, Guri Hospital, Guri, Korea
| | - Seunghun Lee
- Department of Radiology, Hanyang University School of Medicine, Seoul Hospital, Seoul, Korea
| | - Yeo Ju Kim
- Department of Radiology, Hanyang University School of Medicine, Seoul Hospital, Seoul, Korea
| | - Soyoung Bang
- Department of Rheumatology, Hanyang University School of Medicine, Guri Hospital, Guri, Korea
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Spinal gout diagnosed by dual-energy CT: A case report. Radiol Case Rep 2022; 17:4135-4138. [PMID: 36105827 PMCID: PMC9465344 DOI: 10.1016/j.radcr.2022.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 12/27/2022] Open
Abstract
Axial gout is an atypical presentation of gout caused by monosodium urate deposition in the axial skeleton. Spinal gout presents nonspecifically and can be a difficult diagnosis. The diagnosis of gout is a clinical one, with imaging and labs providing supporting evidence. Current imaging modalities such as magnetic resonance, computed tomography, and X-ray can be nonspecific and lead to invasive procedures for diagnosis. Dual-energy computed tomography allows clear visualization of urate collection and is a valuable tool to make a confident diagnosis of spinal gout. Here, we present a case of a man with longstanding severe gout in which dual-energy computed tomography played a key role in diagnosis.
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Five material tissue decomposition by dual energy computed tomography. Sci Rep 2022; 12:17117. [PMID: 36224229 PMCID: PMC9556609 DOI: 10.1038/s41598-022-21193-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/23/2022] [Indexed: 01/04/2023] Open
Abstract
The separation of mixtures of substances into their individual components plays an important role in many areas of science. In medical imaging, one method is the established analysis using dual-energy computed tomography. However, when analyzing mixtures consisting of more than three individual basis materials, a physical limit is reached that no longer allows this standard analysis. In addition, the X-ray attenuation coefficients of chemically complicated basis materials may not be known and also cannot be determined by other or previous analyses. To address these issues, we developed a novel theoretical approach and algorithm and tested it on samples prepared in the laboratory as well as on ex-vivo medical samples. This method allowed both five-material decomposition and determination or optimization of the X-ray attenuation coefficients of the sample base materials via optimizations of objective functions. After implementation, this new multimodal method was successfully tested on self-mixed samples consisting of the aqueous base solutions iomeprol, eosin Y disodiumsalt, sodium chloride, and pure water. As a first proof of concept of this technique for detailed material decomposition in medicine we analyzed exact percentage composition of ex vivo clots from patients with acute ischemic stroke, using histological analysis as a reference standard.
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Baffour FI, Ferrero A, Aird GA, Powell GM, Adkins MC, Bekele DI, Johnson MP, Fletcher JG, Glazebrook KN. Evolving Role of Dual-Energy CT in the Clinical Workup of Gout: A Retrospective Study. AJR Am J Roentgenol 2022; 218:1041-1050. [PMID: 35080455 DOI: 10.2214/ajr.21.27139] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND. Dual-energy CT (DECT) allows noninvasive detection of monosodium urate (MSU) crystal deposits and has become incorporated into the routine clinical evaluation for gout at many institutions over the past decade. OBJECTIVE. The purpose of this study was to compare two time periods over the past decade in terms of radiologists' interpretations of DECT examinations performed for the evaluation of gout and subsequent clinical actions. METHODS. This retrospective study included 100 consecutive adult patients who underwent DECT to evaluate for gout in each of two periods (one beginning in March 2013 and one beginning in September 2019). Examinations performed in 2013 were conducted using a second-generation DECT scanner (80 kV [tube A] and 140 kV [tube B] with a 0.4-mm tin filter), and those performed in 2019 were conducted using a third-generation DECT scanner (80 kV [tube A] and 150 kV [tube B] with a 0.6-mm tin filter) that provides improved spectral separation. Original DECT reports were classified as positive, negative, or equivocal for MSU crystals indicative of gout. Joint aspirations occurring after the DECT examinations were recorded on the basis of findings from medical record review. A single radiologist performed a post hoc retrospective blinded image review, classifying examinations as positive, negative, or equivocal. RESULTS. In 2013, 44.0% of DECT examinations were interpreted as positive, 23.0% as negative, and 33.0% as equivocal; in 2019, 37.0% were interpreted as positive, 47.0% as negative, and 16.0% as equivocal (p < .001). The frequency of joint aspiration after DECT was 14.0% in 2013 versus 2.0% in 2019 (p = .002), and that after DECT examinations with negative interpretations was 17.4% in 2013 versus 2.1% in 2019 (p = .02). In post hoc assessment by a single radiologist, the distribution of interpretations in 2013 was positive in 49.0%, negative in 22.0%, and equivocal in 29.0%, and in 2019 it was positive in 39.0%, negative in 50.0%, and equivocal in 11.0% (p < .001). CONCLUSION. When DECT examinations performed for gout in 2013 and 2019 were compared, the frequency of equivocal interpretations was significantly lower in 2019, possibly in relation to interval technologic improvements. Negative examinations were less frequently followed by joint aspirations in 2019, possibly reflecting increasing clinical acceptance of the DECT results. CLINICAL IMPACT. The findings indicate an evolving role for DECT in the evaluation of gout after an institution's routine adoption of the technology for this purpose.
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Affiliation(s)
- Francis I Baffour
- Department of Radiology, Division of Musculoskeletal Imaging, Mayo Clinic, 200 2nd St SW, Rochester, MN 55902
| | - Andrea Ferrero
- Department of Radiology, Division of Medical Physics, Mayo Clinic, Rochester, MN
| | | | - Garret M Powell
- Department of Radiology, Division of Musculoskeletal Imaging, Mayo Clinic, 200 2nd St SW, Rochester, MN 55902
| | - Mark C Adkins
- Department of Radiology, Division of Musculoskeletal Imaging, Mayo Clinic, 200 2nd St SW, Rochester, MN 55902
| | - Delamo I Bekele
- Department of Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
| | - Matthew P Johnson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Joel G Fletcher
- Department of Radiology, Division of Abdominal Imaging, Mayo Clinic, Rochester, MN
| | - Katrina N Glazebrook
- Department of Radiology, Division of Musculoskeletal Imaging, Mayo Clinic, 200 2nd St SW, Rochester, MN 55902
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Vicentini JR, Chang CY. MR Imaging of the Knee Bursae and Bursal Pathology. Magn Reson Imaging Clin N Am 2022; 30:241-260. [DOI: 10.1016/j.mric.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Habibollahi S, Lozano-Calderon S, Chang CY. Common Soft Tissue Mass-like Lesions that Mimic Malignancy. Radiol Clin North Am 2022; 60:301-310. [DOI: 10.1016/j.rcl.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Bajaj G, Callan AK, Weinschenk RC, Chhabra A. Multiparametric Evaluation of Soft Tissue Sarcoma: Current Perspectives and Future Directions. Semin Roentgenol 2022; 57:212-231. [DOI: 10.1053/j.ro.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
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Shin DH, Song YS, Choi Y, Yoo WH, Kummel F, Park EH. Clumpy artifacts can be differentiated from tophi with DECT: comparison between gout-free and gouty patients. Br J Radiol 2022; 95:20210990. [PMID: 34767489 PMCID: PMC8722253 DOI: 10.1259/bjr.20210990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To accurately differentiate clumpy artifacts from tophi with foot and ankle DECT. METHODS AND MATERIALS In session 1, 108 clumpy artifacts from 35 patients and 130 tophi images from 25 patients were analyzed. Reviewers classified green pixelation according to anatomic location, shape (linear, stippled, angular, oval), and height and width ratio. In session 2, green pixelation confined to the tendon was evaluated (shape, height and width ratio, occupied area in the tendon, accompanied peritendinous green pixelation). RESULTS In session 1, while tophi were noted at various locations, almost all clumpy artifacts were located at the tendon (99%, p < 0.0001). Most clumpy artifacts were linear, stippled, and wide, while most tophi were angular and oval (p < 0.05). In session 2, the shape of green pixelation from clumpy artifacts and tophi was significantly different (p < 0.0001) and most clumpy artifacts occupied less than 50% of the tendon (p = 0.02), and most tophi were accompanied by peritendinous green pixelation (p < 0.0001). Univariant logistic regression showed that tophi were significantly correlated with peritendinous deposits, angular and oval shape, and more than 50% of the tendon (p < 0.05). CONCLUSION Clumpy artifacts can be differentiated from tophi in DECT. Clumpy artifacts typically are located in the tendon with a linear or stippled shape, wide, and less than 50% of a tendon's cross-section. Tophi, on the other hand, typically are oval, larger than 50% of the tendon's cross-section, and associated with adjacent peritendinous green pixelation. ADVANCES IN KNOWLEDGE Clumpy artifacts can be differentiated from tophi in image findings by their location and shape.
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Affiliation(s)
- Dong Han Shin
- Department of Radiology, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - You Seon Song
- Department of Radiology, Pusan National University Hospital, Biomedical Research Institute, Pusan, Republic of Korea
| | | | | | - Florian Kummel
- SHS DI CT M&S PCMM, Siemens Healthcare GmbH, Forchheim, Germany
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18
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Weaver JS, Vina ER, Munk PL, Klauser AS, Elifritz JM, Taljanovic MS. Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging. J Clin Med 2021; 11:jcm11010166. [PMID: 35011907 PMCID: PMC8745871 DOI: 10.3390/jcm11010166] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/16/2021] [Accepted: 12/26/2021] [Indexed: 12/22/2022] Open
Abstract
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.
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Affiliation(s)
- Jennifer S. Weaver
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Correspondence:
| | - Ernest R. Vina
- Department of Medicine, University of Arizona Arthritis Center, Tucson, AZ 85724, USA;
| | - Peter L. Munk
- Department of Radiology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- Department of Radiology, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Andrea S. Klauser
- Radiology Department, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
| | - Jamie M. Elifritz
- Departments of Radiology and Pathology, University of New Mexico, Albuquerque, NM 87131, USA;
- New Mexico Office of the Medical Investigator, Albuquerque, NM 87131, USA
| | - Mihra S. Taljanovic
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Departments of Medical Imaging and Orthopaedic Surgery, University of Arizona, Tucson, AZ 85721, USA
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Green CA, Solomon JB, Ruchala KJ, Samei E. Design and implementation of a practical quality control program for dual-energy CT. J Appl Clin Med Phys 2021; 22:249-260. [PMID: 34472700 PMCID: PMC8504583 DOI: 10.1002/acm2.13396] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/10/2021] [Accepted: 07/16/2021] [Indexed: 12/16/2022] Open
Abstract
A novel routine dual‐energy computed tomography (DECT) quality control (QC) program was developed to address the current deficiency of routine QC for this technology. The dual‐energy quality control (DEQC) program features (1) a practical phantom with clinically relevant materials and concentrations, (2) a clinically relevant acquisition, reconstruction, and postprocessing protocol, and (3) a fully automated analysis software to extract quantitative data for database storage and trend analysis. The phantom, designed for easy set up for standalone or adjacent imaging next to the ACR phantom, was made in collaboration with an industry partner and informed by clinical needs to have four iodine inserts (0.5, 1, 2, and 5 mg/ml) and one calcium insert (100 mg/ml) equally spaced in a cylindrical water‐equivalent background. The imaging protocol was based on a clinical DECT abdominal protocol capable of producing material specific concentration maps, virtual unenhanced images, and virtual monochromatic images. The QC automated analysis software uses open‐source technologies which integrates well with our current automated CT QC database. The QC program was tested on a GE 750 HD scanner and two Siemens SOMATOM FLASH scanners over a 3‐month period. The automated algorithm correctly identified the appropriate region of interest (ROI) locations and stores measured values in a database for monitoring and trend analysis. Slight variations in protocol settings were noted based on manufacturer. Overall, the project proved to provide a convenient and dependable clinical tool for routine oversight of DE CT imaging within the clinic.
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Affiliation(s)
- Crystal A Green
- Department of Radiology, Clinical Imaging Physics Group, Duke University Medical Center, Durham, North Carolina, USA
| | - Justin B Solomon
- Clinical Imaging Physics Group, Carl E. Ravin Advanced Imaging Laboratories, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Ehsan Samei
- Department of Radiology, Clinical Imaging Physics Group, Carl E. Ravin Advanced Imaging Laboratories, Duke University Medical Center, Durham, North Carolina, USA
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Huang Z, Li Z, Xiao J, Xie Y, Hu Y, Zhang S, Wang X. Dual-energy computed tomography for the diagnosis of acute gouty arthritis. Curr Med Imaging 2021; 18:305-311. [PMID: 34238168 DOI: 10.2174/1573405617666210707164124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/21/2021] [Accepted: 05/25/2021] [Indexed: 11/22/2022]
Abstract
AIMS To investigate the diagnostic value of dual-energy computed tomography (DECT) in acute gouty arthritis (AGA) or patients presenting with suspected gouty arthritis. METHODS This retrospective study was performed in a single centre from May 2017 to August 2018. Two hundred and twenty-six patients with an initial diagnosis of AGA in the preceding 15 days were included. All patients were referred for a DECT scan of the affected joints. The diagnosis criteria of gout with the American College of Rheumatology Classification Standard were regarded as the reference standard. RESULTS Two hundred patients were included in the present study at last. The sensitivity, specificity, positive predictive value, and negative predictive value of DECT in the diagnosis of all AGA were 83.83%, 60.61%, 91.5% and 42.55% respectively. When AGA was subdivided according to the joint site, the sensitivity, specificity, positive predictive value, and negative predictive value were 80.68%, 61.11%, 91.03%, and 39.29% in feet, 93.55%, 40%, 93.55%, and 40% in knees and 87.5%, 71.43%, 91.3%, and 62.5% in ankles, respectively. CONCLUSIONS DECT had a high sensitivity for the diagnosis of AGA. However, the specificity was limited, particularly for the diagnosis of acute gouty knee arthritis. Prospective multicenter studies of large samples will enhance the application of DECT among the AGA patients in the future.
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Affiliation(s)
- Zengfa Huang
- Department of Radiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, 26 Shengli Avenue, Jiangan, Wuhan, Hubei 430014, China
| | - Zuoqin Li
- Department of Radiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, 26 Shengli Avenue, Jiangan, Wuhan, Hubei 430014, China
| | - Jianwei Xiao
- Department of Radiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, 26 Shengli Avenue, Jiangan, Wuhan, Hubei 430014, China
| | - Yuanliang Xie
- Department of Radiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, 26 Shengli Avenue, Jiangan, Wuhan, Hubei 430014, China
| | - Yun Hu
- Department of Radiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, 26 Shengli Avenue, Jiangan, Wuhan, Hubei 430014, China
| | - Shutong Zhang
- Department of Radiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, 26 Shengli Avenue, Jiangan, Wuhan, Hubei 430014, China
| | - Xiang Wang
- Department of Radiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, 26 Shengli Avenue, Jiangan, Wuhan, Hubei 430014, China
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21
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Lee JS, Seo WJ. What is the diagnostic value of dual-energy computed tomography in patients with clinical diagnosis of gout? Adv Rheumatol 2021; 61:40. [PMID: 34187593 DOI: 10.1186/s42358-021-00198-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/16/2021] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To investigate the frequency of monosodium urate (MSU) crystal deposits on dual-energy computed tomography (DECT) in patients with clinical diagnosis of gout and the factors associated MSU crystal positivity. METHODS This study was conducted in patients with clinical diagnosis of gout who underwent DECT. Clinical features were compared between patients with positive and those with negative DECT results. A logistic regression analysis was performed to determine the factors associated with MSU crystal positivity on DECT. RESULTS A total of 148 patients with clinical diagnosis of gout were included, and MSU crystal deposition on DECT was observed in 64 patients (43.3%). The patients with positive DECT results were more likely to have renal insufficiency, longer disease duration, and higher serum urate level than those with negative. In the multivariable analysis, first gout attack (odds ratio 0.462; 95% confidence interval 0.229-0.931, p = 0.031) was associated with a less likely MSU crystal deposit-positive DECT result. In the subgroup analysis of patients with first attack, serum urate level > 8 mg/dL was associated with DECT positivity. CONCLUSION Of the patients with clinical diagnosis of gout, those with renal insufficiency, longer disease duration, and high serum urate level were more likely to be positive of gout on DECT. First gout attack was associated with less likely to be positive for MSU crystal on DECT. Thus, performing DECT scan in the selected patients who had characteristics that highly probability of DECT positivity could increase positive predictive value.
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Affiliation(s)
- Jung Sun Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul Veterans Hospital, 53 Jinhwangdo-ro 61-gil Gangdong-gu, Seoul, 05368, South Korea.
| | - Wook Jang Seo
- Division of Rheumatology, Department of Internal Medicine, Seoul Veterans Hospital, 53 Jinhwangdo-ro 61-gil Gangdong-gu, Seoul, 05368, South Korea
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Tang T, Han FG. Calcium pyrophosphate deposition disease of the temporomandibular joint invading the middle cranial fossa: Two case reports. World J Clin Cases 2021; 9:2662-2670. [PMID: 33889634 PMCID: PMC8040178 DOI: 10.12998/wjcc.v9.i11.2662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/03/2021] [Accepted: 02/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pseudogout is a benign joint lesion caused by the deposition of calcium pyro-phosphate dihydrate crystals, but it is invasive. Pseudogout of the temporo-mandibular joint (TMJ) is uncommon, and it rarely invades the skull base or penetrates into the middle cranial fossa. The disease has no characteristic clinical manifestations and is easily misdiagnosed.
CASE SUMMARY We present two cases of tophaceous pseudogout of the TMJ invading the middle cranial fossa. A 46-year-old woman with a history of diabetes for more than 10 years was admitted to the hospital due to swelling and pain in the right temporal region. Another patient, a 52-year-old man with a mass in the left TMJ for 6 years, was admitted to the hospital. Maxillofacial imaging showed a calcified mass and severe bone destruction of the skull base in the TMJ area. Both patients underwent excision of the lesion. The lesion was pathologically diagnosed as tophaceous pseudogout. The symptoms in these patients were relieved after surgery.
CONCLUSION Tophaceous pseudogout should be considered when there is a calcified mass in the TMJ with or without bone destruction. A pathological examination is the gold standard for diagnosing this disease. Surgical treatment is currently the recommended treatment, and the prognosis is good after surgery.
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Affiliation(s)
- Ting Tang
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Fu-Gang Han
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
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Ayoub S, Rajamohan AG, Acharya J, Gross J, Patel V. Chronic tophaceous gout causing lumbar spinal stenosis. Radiol Case Rep 2020; 16:237-240. [PMID: 33304433 PMCID: PMC7708751 DOI: 10.1016/j.radcr.2020.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/11/2020] [Indexed: 12/23/2022] Open
Abstract
Gout is a common cause of inflammatory arthritis, typically affecting the joints of the appendicular skeleton. In this report, we present the relatively less common scenario of chronic tophaceous gout affecting the lumbar spine and pelvis, complicated by compressive neuropathy, and notable for its advanced initial presentation in a young patient. We review the pathophysiology underlying gout and discuss its clinical and laboratory presentation. We also use our case as an example to present the radiographic, CT, and MR imaging features of gout affecting the lumbar spine, which can often present a diagnostic dilemma. Finally, we discuss therapeutic options for gout resulting in spinal canal compromise, which include interventions not commonly performed for gout elsewhere in the body.
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Affiliation(s)
- Samantha Ayoub
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anandh G. Rajamohan
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jay Acharya
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jordan Gross
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Vishal Patel
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Corresponding author.
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Sauter AP, Ostmeier S, Nadjiri J, Deniffel D, Rummeny EJ, Pfeiffer D. Iodine concentration of healthy lymph nodes of neck, axilla, and groin in dual-energy computed tomography. Acta Radiol 2020; 61:1505-1511. [PMID: 32064891 DOI: 10.1177/0284185120903448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lymph nodes (LN) are examined in every computed tomography (CT) scan. Until now, an evaluation is only possible based on morphological criteria. With dual-energy CT (DECT) systems, iodine concentration (IC) can be measured which could conduct in an improved diagnostic evaluation of LNs. PURPOSE To define standard values for IC of cervical, axillary, and inguinal LNs in DECT. MATERIAL AND METHODS Imaging data of 297 patients who received a DECT scan of the neck, thorax, abdomen-pelvis, or a combination of those in a portal-venous phase were retrospectively collected from the institutional PACS. No present history of malignancy, inflammation, or trauma in the examined region was present. For each examined region, the data of 99 patients were used. The IC of the three largest LNs, the main artery, the main vein, and a local muscle of the examined area was measured, respectively. RESULTS Normalization of the IC of LNs to the artery, vein, muscle, or a combination of those did not lead to a decreased value-range. The smallest range and confidence interval (CI) of IC was found when using absolute values of IC for each region. Hereby, mean values (95% CI) for IC of LN were found: 2.09 mg/mL (2.00-2.18 mg/mL) for neck, 1.24 mg/mL (1.16-1.33 mg/mL) for axilla, and 1.11 mg/mL (1.04-1.17 mg/mL) for groin. CONCLUSION The present study suggests standard values for IC of LNs in dual-layer CT could be used to differentiate between healthy and pathological lymph nodes, considering the used contrast injection protocol.
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Affiliation(s)
- Andreas P Sauter
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Diagnostic and Interventional Radiology, Munich, Germany
| | - Sophie Ostmeier
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Diagnostic and Interventional Radiology, Munich, Germany
| | - Jonathan Nadjiri
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Diagnostic and Interventional Radiology, Munich, Germany
| | - Dominik Deniffel
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Diagnostic and Interventional Radiology, Munich, Germany
| | - Ernst J Rummeny
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Diagnostic and Interventional Radiology, Munich, Germany
| | - Daniela Pfeiffer
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Diagnostic and Interventional Radiology, Munich, Germany
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25
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Role of Dual Energy CT in Diagnosis and Management of Gout. J Clin Rheumatol 2020; 26:e183-e184. [DOI: 10.1097/rhu.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Deniffel D, Sauter A, Fingerle A, Rummeny EJ, Makowski MR, Pfeiffer D. Improved differentiation between primary lung cancer and pulmonary metastasis by combining dual-energy CT-derived biomarkers with conventional CT attenuation. Eur Radiol 2020; 31:1002-1010. [PMID: 32856165 PMCID: PMC7813728 DOI: 10.1007/s00330-020-07195-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/26/2020] [Accepted: 08/13/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess the clinical utility of dual-energy CT (DE-CT)-derived iodine concentration (IC) and effective Z (Zeff) in addition to conventional CT attenuation (HU) for the discrimination between primary lung cancer (LC) and pulmonary metastases (PM) from different primary malignancies. METHODS DE-CT scans of 79 patients with LC (3 histopathologic subgroups) and 89 patients with PM (5 histopathologic subgroups) were evaluated. Quantitative IC, Zeff, and conventional HU values were extracted and normalized to the thoracic aorta. Differences between groups were assessed by pairwise Welch's t test. Correlation and linear regression analyses were used to examine the relationship of imaging parameters in LC and PM. Diagnostic accuracy was measured by the area under receiver operator characteristic curve (AUC) and validated based on resampling methods. RESULTS Significant differences between subgroups of LC and PMs were noted for all imaging parameters, with the highest number of significant pairs for IC. In univariate analysis, only IC was a significant diagnostic feature for discriminating LC from PM (p = 0.03). All quantitative imaging parameters correlated significantly (p < 0.0001, respectively), with the highest correlation between IC and Zeff (r = 0.91), followed by IC and HU (r = 0.76) and Zeff and HU (r = 0.73). Diagnostic models combining IC or Zeff with HU (IC+HU: AUC = 0.73; Zeff+HU: AUC = 0.69; IC+Zeff+HU: AUC = 0.73) were not significantly different and outperformed individual parameters (IC: AUC = 0.57; Zeff: AUC = 0.57; HU: AUC = 0.55) in diagnostic accuracy (p < 0.05, respectively). CONCLUSION DE-CT-derived IC or Zeff and conventional HU represent complementary imaging parameters, which, if used in combination, may improve the differentiation between LC and PM. KEY POINTS • Individual quantitative imaging parameters derived from DE-CT (iodine concentration, effective Z) and conventional CT (HU) provide complementary diagnostic information for the differentiation of primary lung cancer and pulmonary metastases. • A combination of conventional HU and DE-CT parameters enhances the diagnostic utility of individual parameters.
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Affiliation(s)
- Dominik Deniffel
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Andreas Sauter
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Alexander Fingerle
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ernst J Rummeny
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Marcus R Makowski
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Daniela Pfeiffer
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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De Vulder N, Chen M, Huysse W, Herregods N, Verstraete K, Jans L. Case Series: Dual-Energy CT in Extra-Articular Manifestations of Gout: Main Teaching Point: Dual-energy CT is a valuable asset in the detection of extra-articular manifestations of gout. J Belg Soc Radiol 2020; 104:27. [PMID: 32524069 PMCID: PMC7274205 DOI: 10.5334/jbsr.2113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/27/2020] [Indexed: 12/27/2022] Open
Abstract
Extra-articular manifestations of gout are common. The Achilles tendon is a frequently affected site, and uric acid deposition may have harmful effects on tendon structure and function. Advanced imaging can aid in early diagnosis, follow-up of disease activity and therapy efficacy. This case series highlights the use of dual-energy CT as a tool in diagnosing gout and in detecting extra-articular manifestations.
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Affiliation(s)
| | | | | | | | | | - Lennart Jans
- Ghent University, BE
- Ghent University Hospital, BE
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28
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Not All Green Is Tophi: The Importance of Optimizing Minimum Attenuation and Using a Tin Filter to Minimize Clumpy Artifacts on Foot and Ankle Dual-Energy CT. AJR Am J Roentgenol 2020; 214:1335-1342. [DOI: 10.2214/ajr.19.22222] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Dual-energy CT in the differentiation of crystal depositions of the wrist: does it have added value? Skeletal Radiol 2020; 49:707-713. [PMID: 31802167 DOI: 10.1007/s00256-019-03343-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the ability of dual-energy computed tomography (DECT) to improve diagnostic discrimination between gout and other crystal arthropathies such as calcium pyrophosphate deposition disease (CPPD) of the wrist in a clinical patient population. MATERIALS AND METHODS This retrospective case-control study included 29 patients with either gout (case group; n = 9) or CPPD (control group; n = 20) who underwent DECT of the wrist for clinically suspected crystal arthropathy. Color-coded urate and enhanced calcium as well as virtual 120 kVe blended images were reconstructed from the DECT datasets. Two independent and blinded readers evaluated each reconstructed dataset for the presence of depositions in 17 predefined regions. Additionally, a global diagnosis was made first for 120 kVe images only, based solely on morphologic criteria, and subsequently for all reconstructed images. RESULTS Sensitivity for the global diagnosis of gout was 1.0 (95% CI 0.63-1) for both DECT and 120 kVe images with specificities of 0.70 (95% CI 0.46-0.87) for DECT and 0.80 (95% CI 0.56-0.93) for 120 kVe images. Color-coded DECT images did not detect more depositions than monochrome standard CT images. CONCLUSION Discrimination of crystal arthropathies of the wrist is limited using DECT and primarily relying on color-coded images. Evaluation of morphologic criteria on standard CT images is essential for accurate diagnosis.
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30
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Sanghavi PS, Jankharia BG. Applications of dual energy CT in clinical practice: A pictorial essay. Indian J Radiol Imaging 2019; 29:289-298. [PMID: 31741598 PMCID: PMC6857256 DOI: 10.4103/ijri.ijri_241_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/15/2019] [Accepted: 10/08/2019] [Indexed: 12/18/2022] Open
Abstract
In dual-energy CT (DECT), two different x-ray spectra are used to acquire two image datasets of the same region, to allow the analysis of energy-dependent changes in the attenuation of different materials. Each type of material demonstrates a relatively specific change in attenuation between images obtained with a high-energy spectrum and those obtained with a low-energy spectrum. Based on the relatively specific change in attenuation with two different energies, material composition information can be obtained to allow tissue characterization. The DECT ability of material differentiation allows bone removal in various CT angiography studies and bone marrow edema depiction, while with material optimization, metal artefacts can be significantly reduced to almost nil. DECT allows material separation to differentiate uric acid crystals from calcium to determine the composition of urinary calculi and to diagnose gout. Using the DECT ability of material decomposition, iodine maps can be generated, which are useful in the evaluation of any enhancing lesion in the body without the need to obtain a plain scan and allow perfusion maps to be created in cases of pulmonary thromboembolism.
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31
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Shi J, Ermann J, Weissman BN, Smith SE, Mandell JC. Thinking beyond pannus: a review of retro-odontoid pseudotumor due to rheumatoid and non-rheumatoid etiologies. Skeletal Radiol 2019; 48:1511-1523. [PMID: 30868232 DOI: 10.1007/s00256-019-03187-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/10/2019] [Accepted: 02/11/2019] [Indexed: 02/02/2023]
Abstract
Retro-odontoid pseudotumor, or mass-like retro-odontoid soft tissue thickening, is an uncommon but important imaging finding that may be associated with rheumatoid arthritis, crystal deposition diseases, as well as non-inflammatory conditions such as cervical degenerative changes and mechanical alterations. Retro-odontoid pseudotumor is commonly associated with atlantoaxial microinstability or subluxation. MRI and CT have an important role in the detection and diagnosis of retro-odontoid pseudotumor. However, due to a wide range of imaging characteristics and ambiguous etiology, it is a frequently misunderstood entity. The purpose of this article is to review relevant anatomy of the craniocervical junction; describe various imaging appearances, pathophysiology and histology in both rheumatoid and non-rheumatoid etiologies; and discuss differential diagnosis of retro-odontoid pseudotumor in order to help guide clinical management.
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Affiliation(s)
- Junzi Shi
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, 02115, USA.
| | - Joerg Ermann
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Barbara N Weissman
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Stacy E Smith
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Jacob C Mandell
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
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Development and validation of a quantitative method for estimation of the urate burden in patients with gouty arthritis using dual-energy computed tomography. Eur Radiol 2019; 30:404-412. [DOI: 10.1007/s00330-019-06350-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/15/2019] [Accepted: 06/28/2019] [Indexed: 12/27/2022]
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Yue D, Li Fei S, Jing C, Ru Xin W, Rui Tong D, Ai Lian L, Luo YH. The relationship between calcium (water) density and age distribution in adult women with spectral CT: initial result compared to bone mineral density by dual-energy X-ray absorptiometry. Acta Radiol 2019; 60:762-768. [PMID: 30249113 DOI: 10.1177/0284185118801139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Calcium (water) density (DCa(Wa)) of gemstone spectral imaging by spectral computed tomography (CT) is a new method of evaluating bone structures. PURPOSE To investigate age-related change of DCa(Wa) of a chosen lumbar vertebra in adult women with spectral CT and the correlation between the DCa(Wa) and bone mineral density (BMD) of dual-energy X-ray absorptiometry (DXA). MATERIAL AND METHODS A total of 305 adult women underwent spectral CT, 127 of whom simultaneously underwent DXA. All the patients were divided into 11 subgroups based on age. DCa(Wa) and BMD were measured at the second lumbar vertebra on the calcium (water)-based material decomposition images of spectral CT and DXA, respectively. A one-way analysis of variance (ANOVA) was performed for the difference of the measurements among adjacent age subgroups. Pearson correlation was used to assess the association between age and DCa(Wa), age and BMD, as well as DCa(Wa) and BMD. RESULTS There was a significant negative correlation between DCa(Wa) and age (r = -0.719) as well as BMD and age(r = -0.851). The mean DCa(Wa) of L2 vertebral body was significantly different between the 40-44- and 45-49-, 45-49- and 50-54-, 55-59- and 60-64-, 65-69- and 70-74-year-old age subgroups. BMD was significantly different between the 35-39- and 40-44-, 45-49- and 50-54-, and 65-69- and 70-74-year-old age subgroups. There was a significant positive correlation between DCa(Wa) and BMD. CONCLUSIONS The DCa(Wa) of lumbar vertebra by spectral CT demonstrated similar age distribution as BMD of DXA and could be used as a method of measuring the vertebral bone mineral density in adult women.
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Affiliation(s)
- Dong Yue
- Department of Radiology, Cancer Hospital of China Medical University, LiaoNing Cancer Hospital, Shenyang, Liaoning, PR China
| | - Sun Li Fei
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, LiaoNing, PR China
| | - Chen Jing
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, LiaoNing, PR China
| | - Wang Ru Xin
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, LiaoNing, PR China
| | - Dong Rui Tong
- Department of Radiology, Cancer Hospital of China Medical University, LiaoNing Cancer Hospital, Shenyang, Liaoning, PR China
| | - Liu Ai Lian
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, LiaoNing, PR China
| | - Ya Hong Luo
- Department of Radiology, Cancer Hospital of China Medical University, LiaoNing Cancer Hospital, Shenyang, Liaoning, PR China
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Sauter AP, Hammel J, Ehn S, Achterhold K, Kopp FK, Kimm MA, Mei K, Laugerette A, Pfeiffer F, Rummeny EJ, Pfeiffer D, Noël PB. Perfusion-ventilation CT via three-material differentiation in dual-layer CT: a feasibility study. Sci Rep 2019; 9:5837. [PMID: 30967601 PMCID: PMC6456734 DOI: 10.1038/s41598-019-42330-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 03/28/2019] [Indexed: 01/30/2023] Open
Abstract
Dual-Energy Computed Tomography is of significant clinical interest due to the possibility of material differentiation and quantification. In current clinical routine, primarily two materials are differentiated, e.g., iodine and soft-tissue. A ventilation-perfusion-examination acquired within a single CT scan requires two contrast agents, e.g., xenon and gadolinium, and a three-material differentiation. In the current study, we have developed a solution for three-material differentiation for a ventilation-perfusion-examination. A landrace pig was examined using a dual-layer CT, and three scans were performed: (1) native; (2) xenon ventilation only; (3) xenon ventilation and gadolinium perfusion. An in-house developed algorithm was used to obtain xenon- and gadolinium-density maps. Firstly, lung tissue was segmented from other tissue. Consequently, a two-material decomposition was performed for lung tissue (xenon/soft-tissue) and for remaining tissue (gadolinium/soft-tissue). Results reveal that it was possible to differentiate xenon and gadolinium in a ventilation/perfusion scan of a pig, resulting in xenon and gadolinium density maps. By summation of both density maps, a three-material differentiation (xenon/gadolinium/soft tissue) can be performed and thus, xenon ventilation and gadolinium perfusion can be visualized in a single CT scan. In an additionally performed phantom study, xenon and gadolinium quantification showed very accurate results (r > 0.999 between measured and known concentrations).
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Affiliation(s)
- Andreas P Sauter
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany.
| | - Johannes Hammel
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Sebastian Ehn
- Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, Garching, Germany
| | - Klaus Achterhold
- Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, Garching, Germany
| | - Felix K Kopp
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Melanie A Kimm
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Kai Mei
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Alexis Laugerette
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Franz Pfeiffer
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany.,Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, Garching, Germany.,Institute for Advanced Study, Technical University of Munich, Garching, Germany
| | - Ernst J Rummeny
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Daniela Pfeiffer
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Peter B Noël
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
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Zhang T, Yang F, Li J, Pan Z. Gout of the axial joint—A patient level systemic review. Semin Arthritis Rheum 2019; 48:649-657. [DOI: 10.1016/j.semarthrit.2018.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/18/2018] [Accepted: 04/29/2018] [Indexed: 12/11/2022]
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Kwee RM, Kwee TC. Calcified or ossified benign soft tissue lesions that may simulate malignancy. Skeletal Radiol 2019; 48:1875-1890. [PMID: 31297550 PMCID: PMC6813287 DOI: 10.1007/s00256-019-03272-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 02/02/2023]
Abstract
The purpose of this article is to review calcified or ossified benign soft tissue lesions that may simulate malignancy. We review the clinical presentations, locations, imaging characteristics, and differential diagnostic considerations of myositis ossificans, tophaceous gout, benign vascular lesions, calcific tendinopathy with osseous involvement, periosteal chondroma, primary synovial chondromatosis, Hoffa's disease, tumoral calcinosis, lipoma with metaplasia, calcifying aponeurotic fibroma, calcific myonecrosis, ancient schwannoma, and Castleman disease.
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Affiliation(s)
- Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700, RB, Groningen, The Netherlands.
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Chung MK, Kim IJ, Hyun H, Hwang JY, Lee J. Relationship between Urate Crystal Deposits Detected by Dual-energy Computed Tomography and Bone Erosions in Symptomatic Gout Patients without Clinically Apparent Tophi. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.2.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Min Kyung Chung
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - In Je Kim
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyeran Hyun
- Department of Radiology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ji Young Hwang
- Department of Radiology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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Flores DV, Mejía Gómez C, Pathria MN. Layered Approach to the Anterior Knee: Normal Anatomy and Disorders Associated with Anterior Knee Pain. Radiographics 2018; 38:2069-2101. [DOI: 10.1148/rg.2018180048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Dyan V. Flores
- From the Department of Radiology, Philippine Orthopedic Center, Institute of Radiology, St Luke’s Medical Center Global City, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (M.N.P.)
| | - Catalina Mejía Gómez
- From the Department of Radiology, Philippine Orthopedic Center, Institute of Radiology, St Luke’s Medical Center Global City, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (M.N.P.)
| | - Mini N. Pathria
- From the Department of Radiology, Philippine Orthopedic Center, Institute of Radiology, St Luke’s Medical Center Global City, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (M.N.P.)
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Chi Z, Du Y, Yan L, Wang D, Zhang H, Huang W, Tang C. Experimental feasibility of dual-energy computed tomography based on the Thomson scattering X-ray source. JOURNAL OF SYNCHROTRON RADIATION 2018; 25:1797-1802. [PMID: 30407192 DOI: 10.1107/s1600577518012663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/06/2018] [Indexed: 06/08/2023]
Abstract
Unlike large-scale and expensive synchrotron radiation facilities, the Thomson scattering X-ray source can provide quasi-monochromatic, energy-tunable and high-brightness X-ray pulses with a small footprint and moderate cost, making it an excellent candidate for dual-energy and multi-energy imaging at laboratories and hospitals. Here, the first feasibility study on dual-energy computed tomography (CT) based on this type of light source is reported, and the effective atomic number and electron-density distribution of a standard phantom consisting of polytetrafluoroethylene, water and aluminium is derived. The experiment was carried out at the Tsinghua Thomson scattering X-ray source with peak energies of 29 keV and 68 keV. Both the reconstructed effective atomic numbers and the retrieved electron densities of the three materials were compared with their theoretical values. It was found that these values were in agreement by 0.68% and 2.60% on average for effective atomic number and electron density, respectively. These results have verified the feasibility of dual-energy CT based on the Thomson scattering X-ray source and will further expand the scope of X-ray imaging using this type of light source.
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Affiliation(s)
- Zhijun Chi
- Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China
| | - Yingchao Du
- Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China
| | - Lixin Yan
- Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China
| | - Dong Wang
- Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China
| | - Hongze Zhang
- Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China
| | - Wenhui Huang
- Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China
| | - Chuanxiang Tang
- Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China
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Abstract
Dual-energy computed tomography (DECT) enables material decomposition and virtual monochromatic images by acquiring 2 different energy X-ray data sets. DECT can detect musculoskeletal pathologic conditions that CT alone cannot, and that would otherwise require MR imaging. In this review, the authors discuss several useful techniques and applications of DECT in musculoskeletal research: virtual monochromatic images, virtual noncalcium images, gout, iodine map, and tendons.
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Affiliation(s)
- Takeshi Fukuda
- Department of Radiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shimbashi, Minato-ku, Tokyo 105-8471, Japan; Department of Radiology, Stony Brook Medicine, HSC Level 4, Room 120, Stony Brook, NY 11794, USA.
| | - Kunihiko Fukuda
- Centre for International Affairs, The Jikei University, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan
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Clinical applications of a computed tomography color “marrow mapping” algorithm to increase conspicuity of nondisplaced trabecular fractures. Emerg Radiol 2018; 26:59-66. [DOI: 10.1007/s10140-018-1631-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 08/01/2018] [Indexed: 01/14/2023]
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Jeon JY, Lee SW, Jeong YM, Baek HJ. The effect of tube voltage combination on image artefact and radiation dose in dual-source dual-energy CT: comparison between conventional 80/140 kV and 80/150 kV plus tin filter for gout protocol. Eur Radiol 2018; 29:1248-1257. [PMID: 29987420 DOI: 10.1007/s00330-018-5622-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/08/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVES In dual-source CT, dual-energy (DE) performance is affected by various X-ray tube voltage combinations with and without tin filter (Sn). The purpose of this study was to assess the utility of the 80/150 Sn kV voltage combination in terms of image artefact and radiation dose for DECT gout protocol, compared with the conventional 80/140 kV. METHODS Seventy-four patients with suspected gout who underwent dual-source DECT examinations scanned at 80/140 kV (n = 37) and at 80/150 Sn kV (n = 37) were included. Patients' age, sex, and serum uric acid levels were matched between the two groups. The types and incidence of image artefacts and radiation dose were evaluated. RESULTS The 80/150 Sn kV group had significantly fewer patients with artefacts, compared to the 80/140 kV group [11 (30 %) of 37 vs 35 (94.6 %) of 37, p < 0.001]. Except for the motion artefact, the rest of the artefacts-skin, nail bed, submillimetre, motion, vascular, beam-hardening, clumpy artefact along tendon-were significantly less observed in the 80/150 Sn kV acquisitions. The dose-length product (DLP) and effective dose were significantly lower for the 80/150 Sn kV acquisitions compared with the 8s0/140 kV scans (DLP: 104.46 ± 10.66 mGy·cm vs 344.70 ± 56.39 mGy·cm, p < 0.001; effective dose: 1.04 ± 0.11 mSv vs 3.45 ± 0.56 mSv, p < 0.001). CONCLUSIONS The 80/150 Sn kV voltage combination in dual-source DECT system could be used as one of the artefact reduction methods while reducing radiation dose for gout protocol when compared to the conventional 80/140 kV. KEY POINTS • DECT has emerged as the leading modality for non-invasive diagnosis of gout. • Various X-ray tube voltage combinations are now feasible in dual-source DECT. • The 80/150 Sn kV acquisition could facilitate artefact reduction in gout protocol.
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Affiliation(s)
- Ji Young Jeon
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea.
| | - Sheen-Woo Lee
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Yu Mi Jeong
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero, 774beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
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Wong WD, Shah S, Murray N, Walstra F, Khosa F, Nicolaou S. Advanced Musculoskeletal Applications of Dual-Energy Computed Tomography. Radiol Clin North Am 2018; 56:587-600. [DOI: 10.1016/j.rcl.2018.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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44
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Sauter AP, Muenzel D, Dangelmaier J, Braren R, Pfeiffer F, Rummeny EJ, Noël PB, Fingerle AA. Dual-layer spectral computed tomography: Virtual non-contrast in comparison to true non-contrast images. Eur J Radiol 2018; 104:108-114. [PMID: 29857855 DOI: 10.1016/j.ejrad.2018.05.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/09/2018] [Accepted: 05/05/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE To evaluate virtual-non-contrast (VNC) images obtained from clinical triphasic scans with a dual-layer spectral computed tomography system regarding accuracy of iodine subtraction. MATERIAL AND METHODS From September to December 2016, 62 consecutive patients who underwent a clinical routine triphasic CT examination were included into this retrospective study. VNC images based on the arterial and portal venous phase were generated. For every patient and every contrast phase, a region-of-interest (ROI) was defined in aorta, liver, renal cortex, spongious bone, fat, muscle and fluid (i.e. gallbladder, urinary bladder), resulting in 2170 ROIs. VNC images were compared to true-non-contrast (TNC) images regarding difference in attenuation. Consistency between VNC images obtained from the arterial and portal venous phase as well as the influence of the initial attenuation on respective VNC images were evaluated. RESULTS Comparison of HU in VNC and TNC images showed a high accuracy of iodine elimination. Mean difference between TNC and VNC images was only 0.5 ± 8.5 HU and >90% of all comparisons showed a difference of less than 15 HU. For all tissues but spongious bone, mean absolute difference between TNC and VNC images was below 10 HU. VNC images derived from the arterial and the portal venous phase showed excellent correlation. The quality of iodine removal in VNC images was not influenced by the original contrast enhancement. However, VNC images cannot be used for evaluation of iodine removal in bone as bone and iodine can hardly be differentiated via spectral CT. CONCLUSION VNC imaging in DL-CT is a promising tool for daily clinical routine. As non-enhanced CT images are essential in multiple clinical situations, the permanent availability of VNC images with dual-layer spectral CT will result in a substantial reduction of radiation exposure and an increased diagnostic value of monophasic contrast-enhanced CT scans.
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Affiliation(s)
- Andreas P Sauter
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany.
| | - Daniela Muenzel
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Julia Dangelmaier
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Rickmer Braren
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Franz Pfeiffer
- Chair of Biomedical Physics, Technische Universität München, Garching, Germany
| | - Ernst J Rummeny
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Peter B Noël
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Alexander A Fingerle
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
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Acute Gouty Knee Arthritis: Ultrasound Findings Compared With Dual-Energy CT Findings. AJR Am J Roentgenol 2018; 210:1323-1329. [PMID: 29702022 DOI: 10.2214/ajr.17.19199] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to compare findings of ultrasound (US) with dual-energy CT (DECT) findings in patients presenting with suspected gouty knee arthritis. SUBJECTS AND METHODS This prospective study included 65 patients (52 men and 13 women; median age, 61.7 years [range, 38-87 years]) with an initial clinical diagnosis of acute gouty knee arthritis who underwent DECT performed using a 128-MDCT scanner and US performed using a 5-18-MHz transducer. Both intra- and extraarticular findings obtained using each modality were tabulated. RESULTS DECT identified gout as the final diagnosis for 52 of 65 patients (80.0%). An alternative diagnosis was confirmed for the remaining 13 patients. US detected gout in 31 of 52 patients (sensitivity, 59.6%) and produced findings negative for gout in seven of 13 patients (specificity, 53.8%). The double contour sign on US was positive for gout in 23 of 52 patients (44.2%) and negative in 12 of 13 patients (92.3%). Extraarticular urate deposition was identified by DECT in 44 of 52 patients, compared with identification by US in 11 of 52 patients (p < 0.001). CONCLUSION The sensitivity of US for the diagnosis of gouty knee arthritis is limited, particularly with respect to extraarticular urate deposition. The double contour sign is the single most valuable sign for the assessment of gouty knee arthritis by US.
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Accuracy of iodine quantification in dual-layer spectral CT: Influence of iterative reconstruction, patient habitus and tube parameters. Eur J Radiol 2018; 102:83-88. [PMID: 29685549 DOI: 10.1016/j.ejrad.2018.03.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 02/12/2018] [Accepted: 03/03/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE Evaluation of the influence of iterative reconstruction, tube settings and patient habitus on the accuracy of iodine quantification with dual-layer spectral CT (DL-CT). MATERIAL AND METHODS A CT abdomen phantom with different extension rings and four iodine inserts (1, 2, 5 and 10 mg/ml) was scanned on a DL-CT. The phantom was scanned with tube-voltages of 120 and 140 kVp and CTDIvol of 2.5, 5, 10 and 20 mGy. Reconstructions were performed for eight levels of iterative reconstruction (i0-i7). Diagnostic dose levels are classified depending on patient-size and radiation dose. RESULTS Measurements of iodine concentration showed accurate and reliable results. Taking all CTDIvol-levels into account, the mean absolute percentage difference (MAPD) showed less accuracy for low CTDIvol-levels (2.5 mGy: 34.72%) than for high CTDIvol-levels (20 mGy: 5.89%). At diagnostic dose levels, accurate quantification of iodine was possible (MAPD 3.38%). Level of iterative reconstruction did not significantly influence iodine measurements. Iodine quantification worked more accurately at a tube voltage of 140 kVp. Phantom size had a considerable effect only at low-dose-levels; at diagnostic dose levels the effect of phantom size decreased (MAPD <5% for all phantom sizes). CONCLUSION With DL-CT, even low iodine concentrations can be accurately quantified. Accuracies are higher when diagnostic radiation doses are employed.
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Dalbeth N, Nicolaou S, Baumgartner S, Hu J, Fung M, Choi HK. Presence of monosodium urate crystal deposition by dual-energy CT in patients with gout treated with allopurinol. Ann Rheum Dis 2018; 77:364-370. [PMID: 29146741 PMCID: PMC5867403 DOI: 10.1136/annrheumdis-2017-212046] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/09/2017] [Accepted: 10/31/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Dual-energy CT (DECT) detects and quantifies monosodium urate (MSU) crystal deposition with high precision. This DECT study assessed crystal deposition in patients with gout treated with stable-dose allopurinol, and investigated potential clinical determinants for crystal deposition. METHODS Patients with gout treated with allopurinol ≥300 mg daily for at least 3 months were prospectively recruited from the USA and New Zealand, using monitored enrolment to include approximately 25% patients with palpable tophi and approximately 50% with serum urate (sUA) levels <6.0 mg/dL (<357µmol/L). MSU crystal deposition was measured in the hands/wrists, feet/ankles/Achilles and knees bilaterally. The presence and total volume of crystals were assessed by DECT and analysed according to sUA levels and gout characteristics. RESULTS Among 152 patients receiving allopurinol ≥300 mg/day for 5.1 years on average, 69.1% had crystal deposition on DECT, with a median total crystal volume of 0.16 cm3 (range: 0.01-19.53 cm3). The prevalence of crystal deposition ranged from 46.9% among patients with sUA <6.0 mg/dL and no palpable tophi to 90.0% among those with sUA ≥6.0 mg/dL and tophi. Total volume of crystal deposition was positively associated with sUA ≥6.0 mg/dL, gout flares within the past 3 months and tophi. Total volume of crystal deposition correlated positively with Patient Global Impression of Disease Activity scores. CONCLUSION A substantial proportion of patients without palpable tophi have MSU crystal deposition, despite receiving allopurinol doses ≥300 mg/day for a considerable duration. Patients with higher sUA and clinical features of severe disease have a higher frequency and greater volume of MSU crystal deposition.
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Affiliation(s)
- Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Savvas Nicolaou
- Department of Radiology, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jia Hu
- Formerly Ardea Biosciences, Inc., San Diego, California, USA
| | - Maple Fung
- Formerly Ardea Biosciences, Inc., San Diego, California, USA
| | - Hyon K Choi
- Department of Rheumatology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
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Ehn S, Sellerer T, Muenzel D, Fingerle AA, Kopp F, Duda M, Mei K, Renger B, Herzen J, Dangelmaier J, Schwaiger BJ, Sauter A, Riederer I, Renz M, Braren R, Rummeny EJ, Pfeiffer F, Noël PB. Assessment of quantification accuracy and image quality of a full-body dual-layer spectral CT system. J Appl Clin Med Phys 2018; 19:204-217. [PMID: 29266724 PMCID: PMC5768037 DOI: 10.1002/acm2.12243] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 10/24/2017] [Accepted: 11/02/2017] [Indexed: 11/20/2022] Open
Abstract
The performance of a recently introduced spectral computed tomography system based on a dual-layer detector has been investigated. A semi-anthropomorphic abdomen phantom for CT performance evaluation was imaged on the dual-layer spectral CT at different radiation exposure levels (CTDIvol of 10 mGy, 20 mGy and 30 mGy). The phantom was equipped with specific low-contrast and tissue-equivalent inserts including water-, adipose-, muscle-, liver-, bone-like materials and a variation in iodine concentrations. Additionally, the phantom size was varied using different extension rings to simulate different patient sizes. Contrast-to-noise (CNR) ratio over the range of available virtual mono-energetic images (VMI) and the quantitative accuracy of VMI Hounsfield Units (HU), effective-Z maps and iodine concentrations have been evaluated. Central and peripheral locations in the field-of-view have been examined. For all evaluated imaging tasks the results are within the calculated theoretical range of the tissue-equivalent inserts. Especially at low energies, the CNR in VMIs could be boosted by up to 330% with respect to conventional images using iDose/spectral reconstructions at level 0. The mean bias found in effective-Z maps and iodine concentrations averaged over all exposure levels and phantom sizes was 1.9% (eff. Z) and 3.4% (iodine). Only small variations were observed with increasing phantom size (+3%) while the bias was nearly independent of the exposure level (±0.2%). Therefore, dual-layer detector based CT offers high quantitative accuracy of spectral images over the complete field-of-view without any compromise in radiation dose or diagnostic image quality.
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Affiliation(s)
- Sebastian Ehn
- Chair of Biomedical PhysicsDepartment of Physics and Munich School of BioEngineeringTechnical University of MunichGarchingGermany
| | - Thorsten Sellerer
- Chair of Biomedical PhysicsDepartment of Physics and Munich School of BioEngineeringTechnical University of MunichGarchingGermany
| | - Daniela Muenzel
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Alexander A. Fingerle
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Felix Kopp
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Manuela Duda
- Chair of Biomedical PhysicsDepartment of Physics and Munich School of BioEngineeringTechnical University of MunichGarchingGermany
| | - Kai Mei
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Bernhard Renger
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Julia Herzen
- Chair of Biomedical PhysicsDepartment of Physics and Munich School of BioEngineeringTechnical University of MunichGarchingGermany
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Julia Dangelmaier
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Benedikt J. Schwaiger
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Andreas Sauter
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Isabelle Riederer
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Martin Renz
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Rickmer Braren
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Ernst J. Rummeny
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Franz Pfeiffer
- Chair of Biomedical PhysicsDepartment of Physics and Munich School of BioEngineeringTechnical University of MunichGarchingGermany
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
| | - Peter B. Noël
- Chair of Biomedical PhysicsDepartment of Physics and Munich School of BioEngineeringTechnical University of MunichGarchingGermany
- Department of diagnostic and interventional RadiologyTechnical University of MunichMunichGermany
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Kransdorf MJ, Murphey MD. Imaging of Soft-Tissue Musculoskeletal Masses: Fundamental Concepts. Radiographics 2017; 36:1931-1948. [PMID: 27726739 DOI: 10.1148/rg.2016160084] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Radiologic evaluation of musculoskeletal soft-tissue masses has changed dramatically with the continued improvements in imaging technology. The integration of advanced imaging has provided the radiologist with a wide range of assessment tools, but as with all powerful arsenals, selection and application of the appropriate imaging method can be problematic. Although the choices available for imaging evaluation of musculoskeletal masses have changed dramatically, the basic objectives of this assessment have remained constant: diagnosis and staging. The basic principles for evaluating musculoskeletal soft-tissue masses and achieving these objectives have not changed. This article addresses application of the current imaging methods to assessment of soft-tissue musculoskeletal masses, emphasizing fundamental concepts. We do not intend to provide a comprehensive review of imaging techniques, but rather to provide a useful review of the concepts needed to select the appropriate initial imaging method, magnetic resonance (MR) imaging field of view, MR imaging sequences, contrast material requirements, and rapid image acquisition techniques. We also address use of the new quantitative techniques of chemical shift and diffusion-weighted imaging. Finally, we review the current uses of computed tomography and ultrasonography. Although the choices available for imaging evaluation of musculoskeletal masses have changed dramatically within the past decade, appropriate application of the fundamental concepts of imaging will maximize the diagnostic utility of imaging examinations. ©RSNA, 2016.
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Affiliation(s)
- Mark J Kransdorf
- From the Department of Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.J.K.); American Institute for Radiologic Pathology, Silver Spring, Md (M.D.M.); and Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (M.D.M.)
| | - Mark D Murphey
- From the Department of Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (M.J.K.); American Institute for Radiologic Pathology, Silver Spring, Md (M.D.M.); and Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (M.D.M.)
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Abstract
Even though, Hippocrates recognized gout as an affection of older men and a product of high living long back in 5th century BC, this painful condition promises to accompany humanity to the 21st century. The incidence is progressively rising and females are also affected in the modern era. There are also regional and ethnic variations in the incidence, the genetics of which is being studied. The recommended best therapy for the acute attacks and long term prophylaxis has improved remarkably in the recent years. However, patients are often treated inadequately and risk factors for their disease are not well explored in daily practice. Although well designed long term studies of current and newer treatment are welcomed, educating doctors especially the primary care physicians who manage majority of gout cases, in optimizing the currently available management options would improve the present care.
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Affiliation(s)
- Binoy J Paul
- Department of General Medicine, KMCT Medical College, Calicut, Kerala, India
| | - Reeta James
- Department of General Medicine, KMCT Medical College, Calicut, Kerala, India
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